Chartered Institution of Water and
Environmental Management (CIWEM)

Fluoridation of Public Water Supplies

Purpose

To outline the main issues relating to fluoridation of public
water supplies, taking account of legislation, water industry
operations and other matters of concern to legislators, regulators,
the public and other stakeholders, particularly in a UK
context.

CIWEM's Position on Fluoridation:

(a) Although fluoridation of public water supplies to reduce
dental caries has been practised since the 1960s, there has always
been a strong element of customer antipathy towards this practice.
There have also been conflicting medical and scientific views on
the merits of fluoridation programmes, contributing to public
scepticism.CIWEM believes that further work must be undertaken to
demonstrate the value and/or disadvantages of fluoridation
programmes. Such work should involve sound science, ethics,
corporate social responsibility and legal considerations.

(b) Through new legislation the Government will enable Local
Health Authorities to revisit those areas of the country which have
identified a health need and yet do not currently have a
fluoridated water supply, subject to consultation with their
communities. CIWEM believes that the consultation process must
be transparent and objective, carried out independently of Local
Health Authorities and provide local people with information that
will enable informed decisions.

(c) An extension of the fluoridation of public water supplies
through new legislation has been well received by the proponents of
fluoridation programmes and those who promote the benefits of
reducing the level of dental caries in young children and the
removal of the stress and discomfort dental surgery causes to young
people. CIWEM believes that any benefits of fluoridation
programmes must be considered in the context of wider public health
provision and that people should have choice in the way they meet
their dental care needs.

(d) Opponents of fluoridation see it as unethical and in
contravention of human rights. They regard fluoridation as "mass
medication" and believe that it ignores the right of individuals to
refuse medication (other than that required to treat a contagious
disease).CIWEM believes that the legal position relating to
fluoridation of public water supplies must not compromise the
ethical position of professionals as they carry out their duties
and meet their responsibilities to the communities they serve.

(e) For the Water Utility Companies that already practice
fluoridation, the process of adding fluoride to water supplies is
well established and benefits from continuous on-line monitoring
with fail-safe-cut-out on a 24/365 basis. CIWEM is concerned
that there may be operational limitations in preventing fluoridated
water being supplied to those people who do not wish their water
supplies to be fluoridated. A further issue is that the health
authority boundaries and water distribution boundaries do not
generally coincide.

(f) The manufacture of chemicals for fluoridation, increased
transportation costs and the disposal of chemical waste/byproducts
may have a detrimental impact on the environment and Health and
Safety implications. CIWEM believes that more research is
required to investigate the environmental impacts of fluoridation
as well as its Health and Safety implications.

(g) Much water contains natural fluoride at varying levels.
Fluoridation therefore requires the level of naturally occurring
fluoride to be monitored closely and dose rates adjusted
accordingly. This will be costly and may introduce risks associated
with the accuracy of measurements and dosing controls, as well as
the reaction and compatibility of natural fluoride compounds with
dosed ones. CIWEM believes that the issue of the impact and
monitoring of natural fluoride levels should be addressed.

(h) CIWEM notes the evidence illustrating the benefits of
fluoridation and also the concern of some of its Members who
believe it is a breach of their human rights. CIWEM has a duty
of care to its Members and will take all reasonable precautions to
ensure that the ethical standing of their profession is not
compromised.

(i) CIWEM is aware of the likely impact on many of its Members
who will have to deal with the unanswered, real and perceived
concerns of customers, communities and professionals, whether they
support fluoridation of public water supplies or not. CIWEM
believes that there is a case for more and better public
information on fluoridation and that the government and the health
agencies have a key role to play in this regard.

(j) CIWEM believes that the full cost of fluoridation,
including any liabilities, should be borne by the Health Protection
Agency.

The Chartered Institution of Water and Environmental
Management (CIWEM) is the leading professional body for the people
who plan, protect and care for the environment and its resources,
providing educational opportunities, independent information to the
public and advice to government. Members in 98 countries include
scientists, engineers, ecologists and students.

Background:

Definition

Fluoride exists as a natural occurring element in many waters,
or can be added to water artificially as a fluoro silicate
solution, which is the by-product of another process. The
prescribed concentration allowable in drinking water is 1.5 parts
of fluoride per million of water.

Existing Arrangements (UK)

Since the 1960s, over 5 million people (about 10% of the UK
population) have received artificially fluoridated water, mainly in
the Midlands, north-east and eastern parts of England.

The mechanism by which the fluoride is added is well established
and benefits from continuous on-line monitoring with
fail-safe-cut-out on a 24/365 basis to achieve a target level of
one part per million.

1. About half a million people in the UK receive water which is
naturally fluoridated at, or about, the optimum level of one part
per million. A further one million people receive water which is
naturally fluoridated at a lower level, but which still confers
some dental benefit. These areas are generally found in a band
running down the eastern side of the country, from Hartlepool in
the north down to parts of Essex.

2. About 5 million people receive water where the fluoride
content has been artificially increased to a level of one part per
million. Major schemes are in operation in Birmingham and
throughout the West Midlands, and also in Tyneside.

3. Water fluoridation is governed by the Water Industry Act
1991. This gave health authorities the responsibility of deciding
the need locally for fluoridation, and the duty of informing the
public and consulting local authorities about any proposals to
fluoridate local water supplies.

4. In 1999/2000 the Centre for Reviews and Dissemination at the
University of York carried out a systematic review of the evidence
on fluoridation. Whilst the Review Team agreed that fluoridation
reduced tooth decay and found no evidence of risks to overall
health, they were critical of the quality of the research available
"and could conclude nothing with confidence".

5. The Government then commissioned the Medical Research Council
(MRC) to consider what further research was required to improve
knowledge about fluoridation and health. Their report, published in
September 2002, identifies areas of uncertainty regarding the
balance of benefits and risks of water fluoridation, makes
recommendations for research to address these uncertainties and
identifies additional information needed by the public to make
informed decisions. The full report is available on the MRC website
at: www.mrc.ac.uk.

6. An amendment to the Water Bill which became law in late 2003
empowers Local Health Authorities to embark on a consultation
process with their communities and if agreement is reached will
require the water companies concerned to fluoridate the water
supply.

CIWEM Water Supply and Quality Panel

Updated March 2012

Note:- CIWEM Policy Position Statements (PPS) represent the
Institution's views on issues at a particular point in time. It is
accepted that situations change as research provides new evidence.
It should be understood, therefore, that CIWEM PPS's are under
constant review, that previously held views may alter and lead to
revised PPSs.PPSs are produced as a consensus
report and do not necessarily represent the view of individual
members of CIWEM.